Metzitzah be-Peh and Protecting Jewish Infants

It is difficult to believe I am writing about meẓiẓah be-peh, that there is a necessity to address this topic once again. Apparently, yet another Jewish infant has succumbed to an infection and died due to the practice of meẓiẓah be-peh. The Brooklyn DA is even now looking into the case. Even if this case of infant death turns out to be unrelated to the meẓiẓah be-peh, the practice of meẓiẓah be-peh among mohalim (Jewish ritual circumcisers) is on the rise, and inevitably, the death-toll will rise with it.

Basic Information
1) What is meẓiẓah be-peh?
It is the act of sucking the blood from the circumcised penis of the infant child by direct oral contact.

2) How do children get ill and die from this?
Since the penis has just been cut, the wound can be infected with any germs present in the mouth of the mohel (Jewish ritual circumciser). Nowadays, the main culprit is herpes, as documented by the New York City health commissioner. In the 19th century it was syphilis and in the 20th century there were cases of tuberculosis and diphtheria; there have certainly been other illnesses as well.

3) What is the purpose of the ritual?
The ritual was originally invented for what were believed to be health benefits. In pre-modern times, before circulation was discovered, it was believed that if too much blood congregated in one spot it could rot and turn to pus, thereby causing illness. The sucking out of the “dangerous” blood shares the same logic as the sucking out of poison from a snake-bite victim.

4) Why is the ritual still done now?
Some believe – mistakenly I will argue – that this ritual is part of the mitzvah (commandment) of milah (circumcision). Others believe that if the rabbis of old thought this practice was healthy, then so it must be, and that anything that has been a part of Jewish practice for centuries cannot possibly be dangerous.

[Note: For a thorough discussion of this, see Dr. Shlomo Sprecher, “Meẓiẓah be-Peh - Therapeutic Touch or Hippocratic Vestige?” Ḥakirah 3 (2006): 15-66. I make much use of this excellent article in this blog-post. Also see some of the response letters in Ḥakirah 4, especially those of Dr. Marc Shapiro, Dr. Debby Koren and, of course, Dr. Sprecher’s response. For an approach similar to the one I am taking in this article, see Cantor Philip Sherman’s “Metzitzah B’Peh - Oral Law?” that appeared in Conversations 6, as well as on the Jewishideas website.]

Meẓiẓah in Halakha
Meẓiẓah is mentioned in the Mishna (m. Shabbat 9:2) when listing all the parts of the circumcision ritual that are permitted on the Sabbath.

One does all the necessities for circumcision on Shabbat, the milah (circumcision), the priyah (uncovering of the corona), and the meẓiẓah (sucking of the wound). One places a poultice and cumin upon [the wound]. If one did not grind [the cumin] before Shabbat one can crush it with one’s teeth and apply it. If one has not mixed wine and oil before Shabbat, one can put each on separately. One cannot make a bandage for it ab initio, but one can wrap a rag around it. If one did not have [a rag] available before Shabbat, one may wrap one around one’s finger and carry it [to the infant], even through someone else’s courtyard.

Clearly, the point of the Mishna is that not only the circumcision itself, but even all the health measures taken to protect the infant afterwards are permitted on Shabbat. Additionally, it is clear that the poultice, the cumin, the bandage, and the wine and oil mixture are all meant as health measures. Where does the meẓiẓah fit in? Does it go with milah and priyah as essential parts of the circumcision ritual or does it go with the poultice and the cumin as part of the medicinal requirements? The answer to this question is made clear in the Babylonian Talmud (b. Shabbat 133b).

Rav Papa said: “Any professional [mohel] that does not suck out [the blood] – this is dangerous and he should be removed from his position.”

Rav Papa states plainly that meẓiẓah is a medical practice. Furthermore, it is such a vital one, in his opinion, that any mohel who is willing to forgo it and risk an infant’s life must be removed from his position. In case this was not sufficiently clear, the Talmud comments further on Rav Papa’s words:

Obviously! From the fact that Shabbat is violated to do this, clearly it is a matter of danger. What might you have thought? That the blood was already pooled [and removing it would not be a Sabbath violation] – we learn that [the blood being sucked out] is still in the skin [and sucking it out would violate Shabbat if it weren’t for the medical necessity.] It is parallel to the poultice and the cumin: just like the poultice and cumin, if one were not to do this it would be dangerous, so too, if one were not to [suck out the blood] it would be dangerous.

In the Talmud’s analysis, the fact that meẓiẓah is a part of the post-circumcision medical intervention is a given: meẓiẓah is a medical intervention parallel to bandaging the wound and applying healing ointments; it is not part of the circumcision itself. To me, this is clearly the intent of the Talmudic passage, although I am aware that this point has been vigorously debated among the halakhic authorities of the past few centuries.

Some, who have found it hard to argue on halakhic grounds, have defended the practice on qabbalistic grounds, claiming that the practice has mystical significance. This may be so – I am not expert in such matters. Nevertheless, qabbalah and its requisite minhagim, in my opinion, do not have the same binding normative force that halakha does. Qabbalistic reasoning cannot be used to define the parameters of mitzvot against the simple meaning of the Talmud; it certainly cannot be used to override health concerns.

Meẓiẓah and Modern Medicine
Modern medicine denies any substantial health benefit to post-circumcision meẓiẓah. Nonetheless, if that were the only critique, the practice could be safely continued as harmless. The problem lies in the fact that, with the discovery of germs and contagion, modern medicine actually demonstrates the dangerous nature of the practice. Sadly, this is the exact opposite of what the practice was invented to do.

In truth, many practices once thought to be helpful have turned out to be harmful, blood-letting being the most obvious example. Once evidence began to accumulate that meẓiẓah was dangerous and that Jewish infants were, in fact, dying because of this practice, the question became, “what to do about it?” The answer has been debated for upwards of two centuries.

Some authorities, such as Chief Rabbi of Israel Yitzhak Herzog and R. Chaim Soloveitchik of Brisk (followed by his son, R. Moshe Soloveitchik and his grandson, R. Yosef Dov Soloveitchik), advocated stopping the practice. Others held on tenaciously to a requirement to do meẓiẓah be-peh. Historically, this bewildering allegiance to the practice can be traced to the Orthodox battle against the early reformers in 19th century Europe. At a time when many early reformers were questioning the need for circumcision altogether a ban was passed among the reformers against meẓiẓah be-peh. In response to this ban, many traditionalists, such as R. Moshe Shik (1807-1879) and R. Samson Raphael Hirsch (1808-1888), dug in their heels and defended the practice.

Despite the difficulty in endorsing the stance taken by these rabbis, it is important to note that in this period of time there was a widespread feeling that traditional religion was under attack and that it was important to defend every last inch of Jewish law and custom, lest one small change lead to an avalanche of irreligiosity. Furthermore, modern medicine as a scientific discipline was still in its early phases.

Nowadays, neither of these factors is operative. Orthodox Judaism has carved for itself a solid niche and cannot reasonably be described as threatened by the Reform movement. Modern medicine has more than established itself as the dominant paradigm, and every school-child knows that an open wound is susceptible to germs from anything with which it comes into contact. Any doctor that would touch an open wound without gloves and sterilized equipment would be opening him- or herself up for a lawsuit. And yet, there are still defenders of meẓiẓah be-peh, even in modern times.

Three Alternative Models
Three models have been suggested to deal with the modern challenges posed by meẓiẓah be-peh; I will call them the clean-bill-of-health model, the meẓiẓah-equivalent model and the ritual-meẓiẓah model. (I am only personally comfortable with the last two, but will explain all three.)

1) The Clean Bill of Health Model
Proposed by R. Dr. Mordechai Halperin, M.D., first in Israel and then in an article in Jewish Action called: “Metzitzah B’peh Controversy: The View from Israel,” the suggestion is to devise a method to ensure that the mohalim who perform meẓiẓah be-peh do not have any illnesses, including sores in the mouth, that can transfer disease. (I have heard that this is the practice in England among mohalim that perform meẓiẓah be-peh.) The mohel would have to go through whatever testing deemed medically necessary to ensure the meẓiẓah is safe, and he would need to constantly renew this clean bill of health. Any mohel without this “license” would be barred from performing meẓiẓah be-peh, and any who did so anyway would be banned from practicing by the community.

Although Halperin’s suggestion is commendable, I am personally uncomfortable with it. Since meẓiẓah be-peh has no medical benefit and no halakhic basis nowadays, I see no reason to continue with a practice that reflects antiquated medicine in such a graphic manner. I feel that doing so, even if it weren’t dangerous, sends the wrong message (this, I hear, is R. Moshe Tendler’s argument as well). Furthermore, I can’t help worrying that even with safeguards, the practice may still pose some threat to the infant; one need only consider the amount of germs and bacteria found in a person’s mouth and the fact that illnesses often come about unexpectedly.

Nevertheless, since there are those that stridently disagree with me and believe meẓiẓah be-peh to be either a halakhic requirement or of paramount qabbalistic significance, I have included the clean-bill-of-health model in the hope that the opposition may at least adopt this, thereby protecting the lives of the infant boys who are otherwise in harm’s way.

2) The Meẓiẓah-Equivalent Model
R. Shlomo Ha-Kohen of Vilna (1828-1905) wrote in a responsum (Binyan Shlomo 2, YD 19) that there is no mitzvah to perform meẓiẓah. Instead, he argued, meẓiẓah should be viewed as part of the general requirement to keep the infant healthy. Therefore, he claims, whatever modern medicine determines to be the best medical practice for keeping the child healthy should be considered the equivalent of meẓiẓah.

According to R. Ha-Kohen, the practice he witnessed in his time period, where the mohel would wrap the penis in rags (smartutin), was the equivalent of meẓiẓah, and that he could not venture to say what the practice would look like in the future. This is because the practice is purely medical and, as he reminds the questioner, he is not a doctor.

Applying Ha-Kohen’s analysis to our times, the modern mohel should sterilize his equipment and use whatever bandages and antibacterial creams are necessary to reduce the risk of infection. In this way he has fulfilled the requirement that is at the root of the – now defunct – requirement to suck out the blood from the wound.

3) The Ritual-Meẓiẓah Model
Some authorities were less comfortable with cancelling the practice altogether, although they were certainly unwilling to risk the lives of Jewish infants to keep it. Hence the idea of a meẓiẓah performed without direct contact between the mohel’s mouth and the infant’s penis was suggested, and two basic forms of this practice were put forward. One idea, advocated by R. Moshe Schreiber (Sofer), known as the Ḥatam Sofer, was to use a sponge around the corona, with the mohel applying (slight) squeezing pressure to remove some blood.

Another method that is popular with a number of Modern Orthodox mohalim today was to use a glass pipet. The mohel would place the pipet upon the wound and suck from the other side, stopping when some blood would come out of the wound. This method was advocated (or at least permitted) by a number of halakhic authorities, such as R. Malkiel Tenenbaum, R. Elyakim Shapiro of Grodno and R. Avraham Kook. It also seems to be the preferred solution of R. Moshe Pirutinsky in his influential compendium, Sefer ha-Brit.

Ancient Rabbis, Ancient Science
One popular response to the critique of the practice of meẓiẓah be-peh has been that if the Sages of old defended the practice, it must be safe and even life-sustaining. It would be beyond the scope of this post to respond in full to this argument, but it is important to note that such an argument suffers from the fallacy of granting the Talmudic Sages superhuman intelligence, making them not only the expositors of traditional Torah laws, but also the repository of all scientific knowledge, past and future. It reflects the belief that the rabbis knew all of science and natural law.

When faced with contradictions between the statements of the rabbis and the reality as described by modern science, some more extreme apologists will even argue that the Talmud is correct and modern physicians are mistaken. This, of course, conflicts with all evidence and any semblance of reason. It reflects the fear that if one admits that the Sages were humans – albeit very wise ones – and that they erred in scientific knowledge, someone could suggest that their views on religion were also in error.

One can appreciate the fear of these ultra-conservatives based on what is at stake. Nevertheless, to me, the very idea that someone would defend a practice that by any reasonable modern standard is dangerous to infants – that has in fact killed a number of infant Jewish boys over the years – in order to support a misguided view of the Talmudic Sages’ infallibility is unfathomable. One cannot hide one’s head in the sand and protect an outdated and fictitious worldview at the expense of the lives of our sons. No matter how small the percentage of deaths may be – and it is admittedly rather small – it is an unacceptable cost for such a paltry return.

Additionally, it appears to me that claiming the performance of meẓiẓah is part of the mitzvah should be considered a distortion of the mitzvah itself. One who makes this claim, despite the obvious evidence from the Talmud to the contrary, is in serious danger of violating the prohibition of bal tosif – the prohibition of adding on to the mitzvot of the Torah. It is well known that one of the categories of this prohibition is changing the form of a mitzvah; the claim that meẓiẓah is a milah-requirement and not a safety-requirement does just that—it changes the form of the mitzvah.

Finally, the ḥillul ha-shem (desecration of God’s name) factor cannot be ignored. Religion in our society is constantly under a microscope. Although Judaism and Torah observance often requires acts that have no objective basis in empirical observation, stemming instead from revelation or tradition, we want to make evident that our religion is not harmful. In the current climate circumcision is controversial enough; the helpful vs. harmful aspects of the practice are being debated in a number of societies across the world even now.

Since circumcision is a Torah commandment as well as a core identity marker for Jews, we have defended this practice – and will continue to do so – in every conceivable manner. However, why should we defend meẓiẓah be-peh, a practice which is not a mitzvah and contains no material benefit to the child, only harm? With medical journals publishing pieces like Benjamen Gesundheit et al.’s Neonatal Genital Herpes Simplex Virus Type 1 Infection after Jewish Circumcision: Modern Medicine and Religious Tradition – Pediatrics 114.2 (2004): 259-263 – the defense of circumcision becomes that much harder, and the idea of Jews being “a light unto the Nations” – well-nigh impossible.

What Would Rav Papa Say?
Perhaps the saddest irony is how the current practice of meẓiẓah be-peh utterly distorts the words of Rav Papa. Rav Papa’s great concern was the safety of Jewish infants, and it was for the sake of safety that he ruled that any mohel who does not perform meẓiẓah should be barred from practice. He believed that skipping this act would endanger the child. Nowadays we understand that the reverse is true: performing this act endangers the child.

If Rav Papa were around today, following his own logic, he would have said that any mohel who touches the open wound without gloves and sterilized instruments – including with his mouth to perform the outdated and discredited medical practice of sucking at an open wound – must be barred from practice. Every mohel who practices meẓiẓah be-peh nowadays is really accomplishing the opposite of what Rav Papa wanted. Moreover, any mohel who does so without ensuring that he has a clean bill of health, thereby, risking the life an infant Jewish boy in the name of Rav Papa, is, in fact, driving a knife into the very heart of Rav Papa himself. A greater insult to a greater man is hardly imaginable.

Suggested Policy
Since this issue cannot be settled with blog-posts and articles, I would like to suggest some practical steps:

For those who cannot accept my interpretation of the halakha and believe that meẓiẓah be-peh is required, and that a pipet or a sponge would not be sufficient – I implore you: at least adopt the clean-bill-of-health model. Consult with physicians and design a healthiness licensing system for your mohalim.

For those that do accept my reading of the halakha – and I assume this is the overwhelming majority of the Modern Orthodox community – we should reject the practice altogether. Meẓiẓah be-peh – at least without the mohel having attained a “clean-bill-of-health” – should be declared a sakkanat nefashot (a life-threatening danger), as it already has been by the New York City Department of Health, and a gratuitous one.

The simple understanding of halakha is that meẓiẓah is not a mitzvah and there are other ways to accomplish it even if it were. Therefore, I suggest the following policies be established in our communities.

Our members will not use mohalim that do meẓiẓah be-peh. Only mohalim that follow either the meẓiẓah-equivalent model (i.e. no meẓiẓah just bandages and sterilization) or ritual-meẓiẓah model (pipet or some other indirect method) will be used.

Our rabbis will not officiate at any brit that has a mohel that does meẓiẓah be-peh.

Our synagogues will not allow the use of our sanctuaries, social halls or any part of our buildings for a brit if there will be meẓiẓah be-peh, at least until such time as these mohalim have instituted an acceptable clean-bill-of-health model.

This is a matter of the safety of our children, and we are accountable for any child that is hurt or dies because we were not strict about this. It is my fervent hope that in taking a strong stance on this issue, all Jewish communities will eventually follow suit. In a matter of life or death, with so much to lose and so little to gain, can we really afford to do less?

Rabbi Zev Farber, Atlanta

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